1043238801 NPI number — FAUSTINO M GONZALEZ II MD

Table of content: FAUSTINO M GONZALEZ II MD (NPI 1043238801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043238801 NPI number — FAUSTINO M GONZALEZ II MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
FAUSTINO
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043238801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2931 N TENAYA WAY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89128-0456
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-981-0216
Provider Business Mailing Address Fax Number:
480-981-1151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4331 E BASELINE RD
Provider Second Line Business Practice Location Address:
STE B106-625
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85234-2961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-834-1211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  23659 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4288971 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00402206 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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